Placental abruption (Complete) Flashcards
Define placental abruption
Premature separation of the placenta from the uterine wall during pregnancy, resulting maternal haemorrhage.
What is the incidence of placental abruption?
1 in 200 pregnancies
What risk factors are associated with placental abruption? (8)
Proteinuric hypertension
* Pre-eclampsia/eclampsia
* Chronic hypertension
Maternal age
(>35 more likely to have vascular disease, hypertension, uterine abnormalities with increasing age)
Smoking or Cocaine use
(Vasoconstrictor resulting in placental ischaemia and abrupt vasospasms)
Maternal trauma (e.g. accident or domestic abuse)
Multiparity
(Weakened uterine arteries)
Polyhydraminos
Coagulation disorders
Previous hx of placental abruption
What are the main clinical features of placental abruption
Symptoms
Abdominal pain
* Sharp and intense
* Sudden onset
Vaginal bleeding
* Typically occurs with abdominal pain
* Can sometimes be concealed
Lower back pain
* More common with posterior/concealed abruptions
Contractions
* High frequency,low volume
Reduced foetal movement
Signs:
‘Woody’ hard uterus
* Tender to palpation and hard
Hypovolaemic shock
* Disproportionate to the amount of vaginal bleeeding
Concealed bleeding is more likely to occur in which types of placental abruption?
Posteriorly located abruptions
What findings on examination are suggestive of placental abruption?
Woody hard uterus
What investigations should be done for patients suspected of placental abruption?
Bedside:
Basic obs: Hypotension
Bloods:
FBC: Check for anaemia
Cross and match: Check blood type for transfusion
Coagulation screen: Check for evidence of impaired coagulation (e.g. DIC)
U&Es: Check kidney function
LFTs: Check liver function
Kleihauer-Betke test: Helps determine the correct anti-D immunoglobulin (anti-D Ig) dose to prevent isoimmunization in rhesus negative woman.
Imaging:
Ultrasound: Rule out placenta praevia
Foetal monitoring (cardiotocography): Done once mother is stable to check foetal viability
Detection of placental abruption on ultrasound has a low detection rate. What findings may occasionally be seen?
Haematoma (hyperechoic/hypoechoic)
Increased placental thickness and echogenicity
Sub-chorionic collection or marginal collection
What differentials should be considered alongside placental abruption?
Placenta praevia
Preterm labour
Chorioamnionitis
Degeneration of uterine fibroid
How does placenta praevia differ to placental abruption?
Onset is quiet and insidious
Painless vaginal bleeding
* More likely to be external and visible
How does preterm labor differ to placental abruption
Bleeding is light versus heavy
Unlikely to have severe abdominal pain, firm uterus, foetal distress
How does chorioamnionitis differ to placental abruption?
Presents with fever
Uterus is tender but soft versus hard/woody
Gradual versus sudden onset
Vaginal bleeding less likely
How does degeneration of uterine fibroid differ to placental abruption
Abdominal pain is localised over the fibroid versus generalised
Vaginal bleeding is rare and more likely to be light/spotting
How are patients with placental abruption managed?
A to E approach
1) Maternal resuscitation
* IV fluid
* Blood transfusion
2) Continous maternal and foetal monitoring
3) Delivery
C-section:
* Unstable maternal or foetal status
Vaginal delivery:
* Stable maternal and foetal status and >34 weeks
Conservative management:
* Stable maternal and foetal status and <34 weeks
Induction of labour: For haemorrhage at term without maternal or foetal compromise
Do NOT delay maternal resuscitation to determine foetal viability
What should be given to rhesus negative woman during management of placental abruption?
Anti-D
Should be given within 72 hours of onset of bleeding
When should a caesarean section be considered in patients with placental abruption?
If there is evidence of unstable maternal/foetal status
When should a vaginal delivery be considered in patients with placental abruption?
If maternal/foetal status is stable and foetus is >34 weeks
When are patients with placental abruption managed conservatively
If maternal/foetal status is stable and gestational age <34 weeks
How are patients with placental abruption managed conservatively?
Supportive:
Continous maternal/foetal monitoring
Medicine:
Corticosteroid: Single dose of corticosteroid (e.g. betamethasone sodium phosphate) between 24th and 34th weeks of gestation.
Magnesium sulphate: Neuroprotection
Surgical:
Consideration of delivery by 37-38 weeks
What complications can occur due to placental abruption? (6)
Preterm brith
Intrauterine growth restriction
Neurological impairment in infant
Acute renal failure
DIC
Perinatal death
